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NPI Code Detail

MEDICARE: DR. JACQUELINE O LUSTIG D.O.

MEDICARE: DR. JACQUELINE O LUSTIG D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician041948CT

General Provider Information

NPI Number : 1245246966
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JACQUELINE O LUSTIG D.O.
Provider Business Mailing Address
First Line : 380 MAIN ST
Second Line :
City : WATERTOWN
State : CT
Zip : 06795-2260
Country : US
Telephone Number : 860-274-8891
Fax Number : 860-274-8895
Provider Business Practice Location Address
First Line : 380 MAIN ST
Second Line :
City : WATERTOWN
State : CT
Zip : 06795-2260
Country : US
Telephone Number : 860-274-8891
Fax Number : 860-274-8895
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/01/2006
Last Update Date : 07/08/2007

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